carbapenem-resistant enterobacteriaceae in north...
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Carbapenem-Resistant Enterobacteriaceae in North Carolina Healthcare
Facilities:
Survey of Hospital Infection Preventionists, Microbiology Laboratories, and Licensed Nursing
Homes (January 1−December 31, 2013)
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Report Table of Contents
CRE Survey Overview .................................................................................................................................................3
I. Infection Preventionist (IP) Survey Results ...............................................................................................................5
A. CRE Prevalence and Frequency of Identification ............................................................................................................ 5
B. Surveillance and Screening ............................................................................................................................................. 6
C. Infection Control & Prevention in Hospitals ................................................................................................................... 7
D. Other Findings ................................................................................................................................................................ 9
E. Antimicrobial Stewardship .............................................................................................................................................. 9
II. Laboratory Survey Results .................................................................................................................................... 11
A. CRE Prevalence and Frequency of Identification .......................................................................................................... 11
B. CRE Detection Methods ................................................................................................................................................ 11
C. Other Laboratory Survey Results .................................................................................................................................. 13
III. Licensed Nursing Home (LNH) Survey Results ....................................................................................................... 15
A. CRE Prevalence and Frequency of Identification .......................................................................................................... 15
B. Surveillance and Screening ........................................................................................................................................... 16
C. Infection Control & Prevention Within Licensed Nursing Homes ................................................................................ 17
D. CRE as an Important Multi-Drug Resistant Organism (MDRO) .................................................................................... 18
E. Education and Training on CRE ..................................................................................................................................... 19
Appendix A. Eligible Acute Care Hospitals by NCHA Region ....................................................................................... 20
Appendix B. Eligible Licensed Nursing Homes by NCHA Region .................................................................................. 21
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CRE Survey Overview
Background
Carbapenem-resistant Enterobacteriaceae (CRE) are a growing public health concern. These organisms are associated with high mortality rates and have the potential to spread widely. In the United States, the most common mechanism of carbapenem resistance is production of the Klebsiella pneumoniae carbapenemase (KPC). Although KPC-producing strains of CRE have been identified in North Carolina, carbapenem resistance can also result from production of less common metallo-β-lactamase enzymes such as New Delhi metallo-β-lactamase (NDM), Verona integrin-encoded metallo-β-lactamase (VIM), and imipenemase metallo-β-lactamase (IMP).
As an initial assessment of CRE prevalence in our state, the North Carolina Division of Public Health (N.C. DPH) and the North Carolina Statewide Program for Infection Control and Epidemiology (N.C. SPICE) distributed a survey to hospital infection preventionists (IPs) and hospital laboratories in 2012. Respondents to the 2012 surveys were asked to report CRE-related information for the 18-month period of January 1, 2011–June 30, 2012.
In 2014, a second survey to IPs and hospital laboratories, and a new survey for licensed nursing homes (LNHs) was distributed. Respondents were asked to report CRE-related information for the period of January 1, 2013–December 31, 2013.
These 2012 and 2014 surveys were specifically developed to determine 1) the prevalence of CRE colonization and infection in North Carolina; 2) current laboratory practices for detecting CRE; and 3) practices used to prevent transmission. The 2014 results also provide baseline information regarding prevalence of and response to CRE in nursing homes. In collaboration with partners, N.C. DPH will use these data to inform current and future surveillance and prevention strategies.
Survey Methods
Survey Design: N.C. DPH developed all surveys using SurveyMonkeyTM. Respondents were asked to provide information for the period January 1, 2013–December 31, 2013. N.C. DPH and N.C. SPICE distributed the surveys through email listservs to the following groups: IPs in all acute care and long-term acute care facilities; hospital-based microbiology laboratories; and administrators for licensed nursing homes. Questions for IP and lab surveys were similar to questions in the 2012 survey. However, new questions were added regarding antibiotic stewardship and laboratory identification methods. Surveys were approved by the N.C. Healthcare-Associated Infection Advisory Group.
Analysis: Eighty-seven acute care hospitals were eligible for inclusion in the survey (Appendix A). Non-acute care hospitals and hospital laboratories that did not test for or confirm CRE were excluded. Laboratories that provided microbiology diagnostic services to either acute care hospitals or nursing homes in North Carolina were eligible for inclusion. Four hundred and ten nursing homes licensed by the N.C. Division of Health Service Regulation were eligible for inclusion in the nursing home survey (Appendix B). Responses lacking requested information regarding frequency of CRE identification were excluded from analysis. Data were analyzed on the state level and on the regional level using six geographic regions defined by the North Carolina Hospital Association (NCHA, Appendices A and B).
Definitions: Based on the N.C. Consensus Guidelines for CRE Screening and Confirmatory Testing published in March, 2014 (http://epi.publichealth.nc.gov/cd/cre/cre_guidance.pdf), CRE were defined as Enterobacteriaceae that are either non-susceptible (intermediate or resistant) to one of the carbapenems tested and resistant to one or more third-generation cephalosporins; OR positive for carbapenemase production by a phenotypic test (e.g., the modified Hodge test (MHT); OR positive for a carbapenemase gene sequence by molecular methods. This differs from the initial survey conducted in 2012, in which CRE were defined as Enterobacteriaceae that were nonsusceptible to one of the carbapenems and resistant to all third-generation cephalosporins tested.
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NOTE: Comparisons are made in this report between the surveys initial distributed in 2012 and those distributed in 2014 for questions that were asked during both surveys. Please note that the 2012 surveys solicited information for an 18-month period, while the 2014 surveys solicited information for a 12-month period.
Summary
Responses were received from IPs at 50/87 (57%) eligible hospitals, from 36 microbiology laboratories serving 49/87 eligible hospitals, and from 146/410 (36%) nursing homes. CRE were identified in all regions within North Carolina during January 1–December 31, 2013. At least one patient with CRE infection or colonization was identified during this period by 36 of 50 (72%) hospitals, 26 of 41 (63%) laboratories, and 22 of 146 (15%) nursing homes. CRE were identified 2–10 times per year in the majority of acute care hospitals responding. Given these findings, all regions in North Carolina were classified as "regions with few CRE identified" during 2013 based on criteria established by CDC and outlined in the 2012 CRE Toolkit.
Discussion
Survey results suggest that CRE continue to be a public health threat in North Carolina hospitals and nursing homes. Overall, the prevalence of CRE colonization and infection reported during 2013 was similar to the prevalence reported during 2011–2012.
In 2014, the NC Division of Public Health collaborated with partners to develop and publish Consensus Guidelines for CRE Screening and Confirmatory Testing. Responses from the 2014 survey indicate that additional laboratories have implemented or will implement the methods in these guidelines.
CRE are generally recognized as epidemiologically important multi-drug resistant organisms by IPs, microbiology laboratory managers, and nursing home facility administrators. IP and laboratory survey responses indicate that an increasing proportion of hospitals are engaging in efforts to identify CRE infection or colonization, such as screening of contacts to known cases; conducting point prevalence surveys; and performing reviews of microbiology records to identify CRE cases. As a result of these actions, facilities were able to identify previously undetected CRE cases. Just over half of responding nursing homes indicated they have or would screen residents epidemiologically-linked to CRE cases, although very few nursing homes performed (or would perform) point prevalence surveys and conducted active surveillance during 2013. Conversely, more than 80% of LNHs reported that they had implemented (or would implement) the majority of measures recommended for control of CRE.
CRE infection or colonization is not currently a reportable condition in North Carolina and is not on the list of nationally notifiable conditions. However, efforts to increase detection and prevention of CRE infections are ongoing. NC DPH is currently working with partners to conduct surveillance for CRE in NC hospitals that participate in the Hospital-Based Public Health Epidemiologist Network (http://epi.publichealth.nc.gov/phpr/phe.html). This sentinel surveillance system will help inform the future of CRE monitoring and response in North Carolina.
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I. Infection Preventionist (IP) Survey Results Infection Preventionists were asked to provide information on the frequency of CRE identification as well as overall awareness and response to CRE during January-December 2013.
2014 IP Survey Summary (comparisons are made to 2012 survey when data are available):
Response rates were lower in 2014 than in 2012 (57% vs. 78%)
Thirty-six hospital IPs (72%) reported at least one patient infected or colonized with CRE during the survey period (compared to 53% in 2012)
CRE identification was evenly distributed among the 6 NCHA regions
More than 85% of responders believed CRE to be epidemiologically important.
A. CRE Prevalence and Frequency of Identification 1. Statewide summary and response rate. Fifty of 87 eligible licensed acute care hospitals in North Carolina
completed surveys in 2014 (response rate of 57%, compared to 78% response rate in 2012). Thirty-six hospitals reported having at least one CRE-infected or -colonized patient present in their facilities, representing 72% of all responding hospitals and 41% of all eligible hospitals (Table 1.1). In 2012, the same number of hospitals (36) reported CRE, representing 53% of responding hospitals and 41% of all eligible hospitals.
Table 1.1 Number of hospitals reporting CRE during January 1, 2013–December 31, 2013
CRE Report Status No. Eligible
Facilities No. Facilities Responding
CRE Status among Responding Facilities
CRE Identified 36 (41%) 50 (57%)
36 (72%)
No CRE identified 14 (16%) 14 (28%)
No Response (CRE Unknown) 37 (43%) 37 (43%) --
Total 87 87 50
2. Regional summary. CRE were reported by facilities in all six regions of the state. The number of acute care hospitals and number reporting CRE are provided in Table 1.2 below.
Table 1.2 Number of hospitals reporting CRE during January 1, 2013–December 31, 2013 by region
NCHA Region No. Facilities No. Facilities Responding
Hospital Response (Survey Completed) CRE
Identified at Facility No CRE
Identified at Facility
1 (Buncombe) 14 7 (50%) 6 (86%) 1 (14%)
2 (Guilford) 15 11 (73%) 7 (64%) 4 (36%)
3 (Wake) 12 9 (75%) 6 (67%) 3 (33%)
4 (Pitt) 15 11 (73%) 8 (73%) 3 (27%)
5 (New Hanover) 13 4 (31%) 2 (50%) 2 (50%)
6 (Mecklenburg) 18 8 (44%) 7 (88%) 1 (12%)
North Carolina 87 50 (57%) 36 (72%) 14 (28%)
3. Reported frequency of CRE identification, by NCHA Region. Overall, a larger proportion of hospitals in each
region indicated that CRE were detected in 2013 compared to 2011-2012, despite the data period being shorter
(Figure 1.1). CRE were most often identified two to 10 times per year in both survey periods.
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Figure 1.1 Frequency of CRE identification among North Carolina hospitals by region –
2011-2012 survey: 2013 survey:
4. Hospital and transfer/community-onset CRE. For the purposes of this survey, IPs were asked to report whether
CRE infections or colonizations were hospital-onset (specimen collected >48 hours after admission) or transfer/community-onset (specimen collected ≤48 hours after admission). There were no apparent differences in the distribution of transfer/community onset or hospital onset between the two survey periods; 40% or fewer were hospital-onset during both periods.
B. Surveillance and Screening Infection preventionists were asked to report implementation of CDC recommendations for detection of CRE-infected or -colonized patients (described in the 2012 CRE Toolkit).
1. CRE screening of epidemiologically linked patients. Persons with CRE may serve as a reservoir for transmission. Screening of patient contacts can be conducted to identify transmission within the facility and is a primary prevention strategy.
Approximately 40% of facilities (19/47 responders) reported they would conduct screening of patient contacts to a CRE case, which is more than twice the proportion who reported that they would screen contacts in the 2011–2012 survey.
Figure 1.2 Proportion of hospitals performing screening of contacts to CRE cases by survey year
2. Point prevalence survey. Point prevalence surveys can be used to rapidly evaluate the prevalence of CRE in a population or unit.
Point prevalence surveys were conducted more frequently in 2013 compared to 2011-2012. Seven (16%) hospitals indicated that a point prevalence survey was conducted in 2013. Of those, 1 reported identifying a previously undetected CRE case as a result.
YES
YES
NO
NO
0% 20% 40% 60% 80% 100%
2011-2012(n=68)
2013(n=47)
If a CRE case is identified, does your
facility conduct testing of patients with
epidemiologic links to the CRE case (e.g., patients in
same unit or who were provided care by same healthcare personnel)?
YES
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Figure 1.3 Proportion of hospitals that have ever conducted a point prevalence survey by survey year
3. Review microbiology records. The review of microbiology records may also be an effective method to detect previously unrecognized or unreported CRE cases.
Twenty-three facilities (47% of responders) reported that they had performed a review of microbiology records, in 2013, compared to 19 (28%) in 2011-2012. Of those 23 hospitals, six (12%) identified previously undetected cases in 2013, compared to 3% in 2011-2012.
Figure 1.4 Proportion of hospitals that have performed a review of microbiology records for CRE
C. Infection Control & Prevention in Hospitals The CDC recommends eight strategies to prevent CRE transmission in the healthcare setting. These strategies are outlined in the 2012 CRE Toolkit and include: 1) hand hygiene, 2) contact precautions, 3) healthcare personnel education, 4) minimizing use of invasive devices, 5) patient and staff cohorting, 6) laboratory notification, 7) promoting antimicrobial stewardship and 8) CRE screening. One objective of this survey was to understand how frequently each of these practices was implemented.
1. Measures implemented. Responses regarding implementation of prevention strategies were similar for the 2011-12 and 2013 survey periods. However, one difference identified during the 2013 survey period was that more facilities indicated they did or would implement patient/staff cohorting (67%) and chlorhexidine bathing (61%).
0% 20% 40% 60% 80% 100%
2011-2012(n=68)
2013(n=45)
Has your facility ever conducted a point
prevalence survey (single round of active surveillance cultures) for CRE in high-risk
units (e.g., units where previously unrecognized
cases were identified, ICU, and units with high
antimicrobial utility)?
YES, NEW CRE CASES IDENTIFIED YES, NO NEW CRE CASES IDENTIFIED NO
0% 20% 40% 60% 80% 100%
2011-2012(n=68)
2013(n=49)
Has your facility ever reviewed microbiology
records over a given time period (e.g. 6 or 12
months) to detect any previously unrecognized or
unreported CRE cases?
YES, NEW CRE CASES IDENTIFIED YES, NO NEW CRE CASES IDENTIFIED NO
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Figure 1.5 Measures implemented when a CRE- infected or -colonized patient is identified
The 2013 survey also asked responders to specify the duration of Contact Precautions. Approximately half of responding facilities indicated that patients would remain on Contact Precautions indefinitely- i.e. for current and future hospitalizations. Figure 1.6 If contact precautions were implemented, duration of contact precautions
2. Transferring OUT of hospital. Inter-facility sharing of patients has the potential to facilitate transmission of CRE and other multi-drug–resistant organisms (MDROs).
Thirty-five facilities (76% of responders) in 2013 reported always or sometimes communicating MDRO/CRE status to receiving facilities, which was lower than during the earlier survey period (97%).
12%
18%
68%
99%
84%
47%
61%
67%
98%
98%
98%
100%
0% 20% 40% 60% 80% 100%
Perform follow-up testing for CRE*
Chlorhexidine bathing for high-risk patientsor patients in high-risk units
Implement Patient and Staff Cohorting
Enhance Hand Hygiene Practices
Dedicate equipment to be used for CREpatient only*
Place on Contact Precautions
Place in single-patient rooms when possible
MEASURES IMPLEMENTED IF CRE IDENTIFIED
2013 (n=49) 2011-2012 (n=68)
*CRE measure not assessed in 2011–2012 survey
2%
8%
18%
23%
49%
0% 20% 40% 60% 80% 100%
Patients not placed on Contact Precautions
For a defined period of time(e.g., 30 days, 6 months, 2 years)
Until patient has screenedculture negative
For duration of hospitalization/until discharge
Indefinitely, Contact Precautions for currentand future hospitalizations
DURATION OF CONTACT PRECAUTIONS
2013 (n=49)
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Figure 1.7 Proportion of hospitals that communicate MDRO status to receiving facilities
3. Transferring INTO hospital. All facilities responding for the 2013 survey period indicated that they sometimes or always inquired about the MDRO status of patients transferred from other facilities. In 2011–2012, only 11 responding facilities (16%) indicated that they regularly inquired about MDRO status of incoming patients.
Figure 1.8 Proportion of hospitals that inquire about MDRO status of incoming transfers
4. Long-term acute care transfer. Long-term acute care hospitals have been identified as having a higher prevalence of CRE infection or colonization as compared to acute care hospitals or nursing homes. Of the 48 responding hospitals, 45 (94%) indicated that they either received patients from or discharged patients to a long-term acute care facility in 2013.
D. Perception of CRE as an Important Multi-Drug Resistant Organism (MDRO) Controlling transmission of CRE in healthcare facilities is dependent upon healthcare facilities recognizing that these organisms are epidemiologically important. Ninety percent of responders (44/49) indicated that their facilities consider CRE to be an epidemiologically important multi-drug resistant organism for which specific infection control practices are indicated to eliminate transmission (compared to 85% for the 2011–2012 survey period).
E. Antimicrobial Stewardship The overuse and misuse of antimicrobial drugs can lead to an increase in colonization and infection with drug-resistant
organisms, such as CRE. Since 2012, the N.C. DPH HAI Prevention Program and its partners have been collaborating to
mitigate drug-resistance. This has included participation in the national Get Smart campaign to encourage appropriate
use of antibiotics. The 2014 CRE survey included new questions to assess hospital antimicrobial stewardship practices
and obtain baseline information on awareness of the problem and implementation of activities to improve antimicrobial
prescribing practices.
0% 20% 40% 60% 80% 100%
2011-2012 (n=68)
2013 (n=46)
If a patient at your facility who is
known to be colonized/infected with
CRE is transferred to another facility, does
someone or would someone from your facility
communicate patient MDRO status (such as CRE,
VRE, MRSA) to receiving facility ?
ALWAYS SOMETIMES NO
0% 20% 40% 60% 80% 100%
2011-2012 (n=68)
2013 (n=49)
If a patient is being transferred TO your facility from another facility, does
someone or would someone from your
facility inquire about patient MDRO status (such as CRE, VRE, MRSA) from
transferring facility?
ALWAYS SOMETIMES NO
NO
N
O
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Of the 50 respondents to the 2014 survey, 64% (n=32) indicated that their facilities had implemented pathogen-specific antibiograms (e.g., summaries indicating percentage of specific pathogens susceptible to various antimicrobials), and 64% (n=32) had also established antimicrobial stewardship committees.
Only 5 (10%) respondents reported that their facilities did not have any antimicrobial stewardship activities implemented in 2013. Lack of physician buy-in, pharmacy staffing shortages, and limited resources were the primary reasons cited by facilities that did not have stewardship activities in place.
Figure 1.9 Antimicrobial stewardship activities implemented – 2013
10%
22%
28%
30%
34%
60%
64%
0% 20% 40% 60% 80% 100%
No antimicrobial stewardship activitiesimplemented
Antibiotic restriction program
Antibiotic physician/pharmacist approvalprocess
Staff dedicated to antimicrobial stewardship
Antibiotic utilization tracking
Antimicrobial stewardship committee
Pathogen-specific antibiograms
ANTIBIOTIC STEWARDSHIP
ACTIVITIES
2013 (n=50)
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II. Laboratory Survey Results
Microbiology laboratories were asked to indicate the number of patients from whom CRE were isolated during January-December 2013. Laboratories were included in the analysis if they provided service to one of the eligible acute care hospitals or licensed nursing homes.
2013 Lab Survey Summary (comparisons are made to 2011-2012 survey when data are available):
Thirty-six eligible laboratories completed the survey, representing 56% of acute care hospitals (compared to 46
eligible laboratories representing 66% of hospitals in 2011–2012).
Seventy-two percent of responding laboratories reported identifying CRE at some point during 2013, compared to
80% in 2011–2012.
Use of automated susceptibility testing to identify CRE was more frequently reported than in the previous survey
(77% in 2013 versus 43% in 2011–2012).
A higher proportion of laboratories reported use of lower breakpoints for carbapenems and cephalosporins in 2013
than during 2011–12, but more than 50% still used the higher breakpoints.
Fewer labs reported having the ability to build a query for CRE in 2013 compared to 2011–2012 (70% versus 90%).
A. CRE Prevalence and Frequency of Identification 1. Statewide summary and response rate. Twenty-six (72%) of the 36 reporting laboratories identified CRE during the 12-month survey period (January - December 2013). This was similar to the proportion of laboratories identifying CRE during the 18-month period covered by the previous survey (80%). Overall, 56% of eligible acute care hospitals were represented by the laboratories responding to the 2013 survey, compared to 66% in 2011-2012.
Among the 49 hospitals covered by reporting laboratories, the median number of CRE-infected or -colonized patients identified over the 12-month survey period was three, with an interquartile range of 0–13. This was similar to the median number of CRE-infected or -colonized patients identified among the 57 hospitals covered by the 2012 survey during the 18-month survey period.
2. Regional summary. Per the laboratory survey, CRE were identified on at least one occasion in all regions of the
state. More than 60% of respondents in each region identified CRE at least once during the survey period. Regional
response rates and the proportion of reporting hospitals in which CRE were identified are presented in Table 2.1.
Table 2.1 Number of laboratories reporting CRE during January 1, 2013–December 31, 2013 by region
NCHA Region No. Laboratories
Completing Survey
No. Laboratories with CRE
Identified
No. Hospitals Represented By
Laboratories
No. Hospitals in Region
% Hospitals Covered by Laboratory
Survey
No. Hospitals with CRE
Identified
1 (Buncombe) 6 5 (83%) 7 14 50% 5 (71%)
2 (Guilford) 5 3 (60%) 6 15 40% 3 (50%)
3 (Wake) 3 2 (67%) 4 12 33% 2 (50%)
4 (Pitt) 10 7 (70%) 12 15 80% 9 (75%)
5 (New Hanover) 7 5 (71%) 8 13 62% 6 (75%)
6 (Mecklenburg) 5 4 (80%) 12 18 67% 6 (50%)
North Carolina 36 26 (72%) 49 87 56% 31 (63%)
B. CRE Detection Methods 1. Testing methods. Laboratories were asked to report testing methods used to identify CRE in clinical specimens. Twenty-eight responders (77%) reported the use of automated susceptibility testing in 2013, a higher proportion than in 2011-2012 (46%). Among those laboratories using automated susceptibility testing, Microscan was used by 20 (59%) and Vitek by 14 (41%); a similar breakdown of automated testing was reported in 2011–2012.
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Figure 2.1 CRE testing methods reported by survey year
2. Antimicrobials. Meropenem was the most common antimicrobial included in commercial AST systems, followed
by ertapenem and imipenen.
Figure 2.2 Antimicrobials included in commercial AST system card or panel – 2013
3. Breakpoints. In 2010 and 2012, the Clinical and Laboratory Standards Institute (CLSI) made changes to the interpretative criteria for determining susceptibility of Enterobacteriaceae to carbapenems. These new criteria lowered the minimum inhibitory concentration (MIC) breakpoints and removed the requirement for carbapenemase testing (e.g., modified Hodge test). Laboratories were asked if the lower CLSI-recommended breakpoints had been implemented and, if not, when they planned to implement them.
Carbapenem breakpoints. Ten responding laboratories (29%) reported using the lower breakpoints in 2013, a slightly higher proportion than in 2011-2012. Approximately 40% of responding laboratories that had not yet implemented the 2012 breakpoints reported that they planned to do so within the next year.
Figure 2.3 Proportion of laboratories using lower carbapenem breakpoints by survey year
Cephalosporin breakpoints. Twelve laboratories(35%) reported using lower breakpoints for cephalosporins in 2013, compared to 7 (16%) in 2011–2012. Six (27%) of the laboratories that had not yet implemented lower breakpoints reported that they planned to do so within the next year.
4%
9%
13%
39%
43%
3%
3%
5%
47%
77%
0% 20% 40% 60% 80% 100%
PCR-based detection of resistance mechanism
Kirby-Bauer disk diffusion
E-test
Modified Hodge test
Automated susceptibility testing
CRE DETECTION METHODS
2013 (n=36) 2011-2012 (n=46)
25%
81%
89%
92%
0% 20% 40% 60% 80% 100%
Doripenem
Imipenem
Ertapenem
Meropenem
Which of the following antimicrobials are included
in your commercial AST system card or panel?
2013 (n=36)
YES
YES
NO
NO
0% 20% 40% 60% 80% 100%
2011-2012 (n=46)
2013 (n=34)Has you laboratory implemented the lower
breakpoints for CARBAPENEMS
recommended in the most recent CLSI guidelines?
13
Figure 2.4 Proportion of laboratories using lower cephalosporin breakpoints by survey year
C. Other Laboratory Survey Results 1. Actions. Laboratories were asked to report what actions were taken when CRE were identified. Most
laboratories reported that they would call the infection prevention department (97%) or call the nursing station (81%). Overall, a larger proportion of responding laboratories reported that they would notify partners in response to CRE in 2013 compared to responses from the 2011-2012 survey period.
Figure 2.5 Reported actions taken when CRE are identified in laboratory by survey year
2. Indicators. In the 2013 survey, laboratories were asked to report if there were specific indicators that would prompt them to suspect CRE. Almost all responders (92%) indicated that ertapenem or other carbapenem intermediate (I) or resistant (R) susceptibility would lead them to suspect a CRE. Ceftriaxone or ceftazidime resistance were also identified as indicators by more than half of laboratories. Figure 2.6 Reported indicators that would prompt laboratory to suspect CRE – 2013
3. CRE query capacity. Laboratories were asked if they had the capacity to build a query for CRE results. Twenty-
four (69%) laboratories reported that they had the capacity in 2013, compared to 41 (90%) in 2011-2012.
YES
YES
NO
NO
0% 20% 40% 60% 80% 100%
2011-2012 (n=45)
2013 (n=34)Has you laboratory implemented the lower
breakpoints for CEPHALOSPORINS
recommended in the most recent CLSI guidelines?
2%
7%
7%
26%
63%
76%
6%
6%
8%
33%
81%
97%
0% 20% 40% 60% 80% 100%
No routine actions
Call State Lab of PH
Report to LHD
Call Physician
Call Nursing Station
Call IP Dept
If CRE were identified in your laboratory, what
further actions would your laboratory routinely take?
2013 (n=36) 2011-2012 (n=46)
42%
56%
56%
92%
0% 20% 40% 60% 80% 100%
ESBL test positive
Ceftazidime-R
Ceftriaxone-R
Ertapenem or other carbapenem-I/R
Are there indicators that would prompt your
laboratory to suspect a CRE?
2013 (n=36)
14
Figure 2.7 Proportion of laboratories having the capacity to build a query for CRE by survey year
YES
YES
NO
NO
0% 20% 40% 60% 80% 100%
2011-2012 (n=45)
2013 (n=35)
Does your facility have the capacity to build a query for
CRE results?
NO
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III. Licensed Nursing Home (LNH) Survey Results
Licensed nursing home (LNH) administrators and staff identified as having infection prevention responsibility were asked to provide information on the frequency of CRE identification as well as the overall awareness of and response to CRE during January-December 2013. This represents the first time N.C. DPH has distributed a CRE survey to these facilities.
2014 LNH Survey Summary:
146 facilities responded to the 2014 survey, representing 36% of all eligible LNHs in North Carolina.
Twenty-two responding LNHs (15%) reported having at least one CRE-infected or -colonized resident during 2013.
More than 60% of LNH respondents reported that their facilities considered CRE to be epidemiologically important.
A. CRE Prevalence and Frequency of Identification 1. Statewide survey and CRE response rate. Twenty-two (15%) of the 146 reporting LNHs identified CRE-
infected or -colonized residents during 2013. Overall response rates and the proportion of reporting facilities in
which CRE were identified are presented in Table 3.1.
Table 3.1 Number of LNHs reporting CRE during January 1, 2013–December 31, 2013
CRE Report Status No. Facilities No. Facilities Responding
CRE Status among Reporting Facilities
CRE Identified 22 (6%) 146 (36%)
22 (15%)
No CRE identified 124 (30%) 124 (85%)
No response 264 (64%) 264 (64%) --
Total 410 410 146
2. Regional summary. CRE were reported by LNHs in five of the six regions of the state. The number of LNHs and number reporting CRE are provided in Table 3.2 below. CRE were identified by more than 30% of responding facilities in Region 2 (Guilford), Region 4 (Pitt), and Region 6 (Mecklenburg).
Table 3.2 Number of nursing homes reporting CRE during January 1, 2013–December 31, 2013 by region
NCHA Region No. Facilities No. Facilities Responding
Hospital Response (Survey Completed) CRE
Identified at Facility No CRE
Identified at Facility
1 (Buncombe) 74 24 (32%) 1 (4%) 23 (96%)
2 (Guilford) 80 36(45%) 5 (44%) 31 (56%)
3 (Wake) 53 19 (36%) 1 (5%) 18 (95%)
4 (Pitt) 63 29 (46%) 10 (34%) 19 (66%)
5 (New Hanover) 59 23 (56%) 0 (0%) 23 (100%)
6 (Mecklenburg) 77 15 (19%) 5 (33%) 10 (67%)
North Carolina 410 146 (36%) 22 (15%) 124 (85%)
3. Reported frequency of CRE identification and transmission. Regional variation in frequency of CRE
identification among LNHs is illustrated in Figure 3.1 below. Among facilities identifying CRE-infected or –
colonized residents, none reported evidence of transmission between residents.
16
Figure 3.1 Frequency of CRE identification among North Carolina LNHs by region – 2013
4. Licensed nursing home characteristics. Respondents to the LNH survey were asked to identify the specific
resident services delivered at their facilities. Responding LNHs reported an average daily census of 98. Only
Two % reported providing services for ventilator-dependent residents.
Figure 3.2 Resident services delivered among LNHs – 2013
B. Surveillance and Screening Licensed nursing home administrators and infection prevention staff were asked to report implementation of CDC recommendations for detection of CRE-infected or -colonized patients (as described in the 2012 CRE Toolkit).
1. CRE screening of epidemiologically linked patients. Fifty-two percent of facilities (65/125) reported that they would screen contacts to an identified CRE case.
0%10%20%30%40%50%60%70%80%90%
100%
Pe
rce
nta
ge
Fa
cili
tie
s R
ep
ort
ing
NCHA Region (No. Facilities Responding)
NO CRE IDENTIFIED
1 RESIDENT
2-5 RESIDENTS
6-10 RESIDENTS
>20 RESIDENTS
2%
29%
51%
68%
73%
95%
0% 20% 40% 60% 80% 100%
Management of residents on a ventilator
Care for residens with dementia in a specialized unit…
Management of residents with a tracheostomy
IV infusions using central lines
Dedicated staff to provide wound care
Skilled nursing/short-term (subacute) rehabiliation
2013 (n=146)
17
Figure 3.3 Proportion of LNHs performing screening of contacts to CRE cases
2. Active surveillance. Active surveillance may be considered for facilities with CRE transmission. Surveillance would include screening patients who meet specified criteria, including high-risk patients or those patients admitted from high-risk settings. Approximately 3% of LNHs (4/133) reported conducting active surveillance testing for CRE in 2013.
Figure 3.4 Proportion of LNHs conducting active surveillance for CRE
3. Point prevalence survey. Point prevalence surveys can be used to rapidly evaluate the prevalence of CRE in a population or unit. Three LNHs (2%) indicated that a point prevalence survey had been conducted during 2013. Of those three, one facility identified a previously unidentified CRE case.
Figure 3.5 Proportion of LNHs that have ever conducted a point prevalence survey
C. Infection Control & Prevention within Licensed Nursing Homes The CDC recommends eight strategies to prevent CRE transmission in the healthcare setting. These strategies are outlined in the 2012 CRE Toolkit and include: 1) hand hygiene, 2) contact precautions, 3) healthcare personnel education, 4) minimizing use of invasive devices, 5) patient and staff cohorting, 6) laboratory notification, 7) promoting antimicrobial stewardship and 8) CRE screening. One objective of this survey was to understand how frequently each of these practices was implemented in LNHs.
The prevention strategies most frequently reported by respondents during 2013 included: 1) placing the patient on
Contact Precautions (90%), 2) enhanced hand hygiene (89%), and 3) dedicated equipment and follow-up testing (86%).
YES NO
0% 20% 40% 60% 80% 100%
2013(n=125)
If a CRE colonized or infected resident is or were to be identified, does your
facility or would your facility conduct testing of close contacts to the CRE
positive resident (e.g., residents in same unit,
same room, or who were provided care by the …
YES
NO
0% 20% 40% 60% 80% 100%
2013(n=133)
Has your facility ever conducted active
surveillance testing (i.e., collection of rectal swabs) to identify residents who may have CRE but do not
have symptoms admitted …
NO
0% 20% 40% 60% 80% 100%
2013(n=135)
Has your facility ever conducted a point
prevalence survey, or a single round of active
surveillance cultures (i.e., rectal swabs), for CRE?
YES, NEW CRE CASES IDENTIFIED YES, NO NEW CRE CASES IDENTIFIED
18
Figure 3.6 Measures implemented when a CRE- infected or -colonized patient is identified
2. Transferring OUT of facility. Inter-facility sharing of patients has the potential to facilitate transmission of CRE and other multi-drug–resistant organisms (MDROs). Ninety-nine percent of respondents (132/133) reported always or sometimes communicating MDRO/CRE status to receiving facilities. Communication most commonly occurred via transfer document (86%) and person-to-person notification (85%).
Figure 3.7 Proportion of facilities that regularly communicate MDRO status to receiving facilities
3. Transferring INTO facility. Ninety-five percent (123/130) of responding LNHs indicated they sometimes or always inquired about the CRE status of incoming patients. Of those, 92 (71%) facilities reported always inquiring. Of the facilities that did inquire about CRE status, person-to-person communication was the primary means of inquiry (89%), followed by use of transfer documents (85%).
Figure 3.8 Proportion of facilities that regularly inquire about MDRO status of incoming transfer patients
D. CRE as an Important Multi-Drug Resistant Organism (MDRO) Controlling transmission of CRE in healthcare facilities is dependent upon healthcare facilities recognizing that these organisms are epidemiologically important.
One hundred twenty-one (91%) of responding LNHs indicated that CRE were important multidrug resistant organisms.
3%
45%
82%
86%
86%
89%
90%
0% 20% 40% 60% 80% 100%
Implement Resident and Staff Cohorting
Chlorhexidine bathing for high-risk patients…
Place in single-resident rooms when possible
Conduct follow-up testing
Dedicate equipment to be used for CRE…
Enhance Hand Hygiene Practices
Place on Contact Precautions
MEASURES IMPLEMENTED IF CRE IDENTIFIED
2013 (n=146)
0% 20% 40% 60% 80% 100%
2013 (n=133)
If a resident at your facility who is known to be
colonized or infected with a multi-drug resistant organism (MDRO) is
transferred FROM your facility to another facility, does someone or would …
ALWAYS SOMETIMES NO
0% 20% 40% 60% 80% 100%
2013 (n=130)
If a resident is being transferred TO your facility from another facility, does
someone or would someone from your facility
inquire about resident MDRO status (such as …
ALWAYS SOMETIMES NON
O
19
Figure 3.9 Proportion of facilities that consider CRE to be epidemiologically important
E. Education and Training on CRE As CRE become increasingly prevalent, education and training to properly identify and prevent CRE (in addition to other MDROs) becomes critical to the public health response. LNH administrators and infection prevention staff were asked to specify receipt of CRE education or training.
Seventy-two (56%) LNH responders indicated staff members have received specific education or training regarding detection and/or prevention of CRE. Among those, 60% obtained CRE information from the N.C. Statewide Program for Infection Control and Epidemiology and 58% utilized CDC resources; 13% referred to other infection control personnel and the N.C. .0206 Infection Prevention in Healthcare Settings course.
Figure 3.10 Sources for education and training regarding CRE detection and/or prevention
0% 20% 40% 60% 80% 100%
2013 (n=133)
In your opinion, does your facility consider
CRE to be an important multidrug-resistant
organism for which specific infection control practices
are needed?
DEFINITELY YES YES UNSURE NO
3%
3%
4%
7%
13%
13%
58%
60%
0% 20% 40% 60% 80% 100%
State Health Department
American Medical Directors Association (AMDA)
Local Health Department
Association for Professionals in Infection…
0206: Infection Prevention in Healthcare…
Infection control personnel (not affiliated…
CDC
N.C. SPICE
CRE EDUCATION AND
TRAINING
2013 (n=72)
NO
20
Appendix A. Eligible Acute Care Hospitals by NCHA Region
FACILITY COUNTY
REGION 1
BLUE RIDGE REGIONAL HOSPITAL, INC MITCHELL
CALDWELL MEMORIAL HOSPITAL, INC. CALDWELL
CATAWBA VALLEY MEDICAL CENTER CATAWBA
FRYE REGIONAL MEDICAL CENTER CATAWBA
GRACE HOSPITAL, INC. BURKE
MARGARET R. PARDEE MEMORIAL HOSPITAL HENDERSON
MEDWEST HARRIS JACKSON
MEDWEST HAYWOOD HAYWOOD
MISSION HOSPITAL BUNCOMBE
MURPHY MEDICAL CENTER, INC. CHEROKEE
PARK RIDGE HEALTH HENDERSON
RUTHERFORD REGIONAL MEDICAL CENTER RUTHERFORD
THE MCDOWELL HOSPITAL MCDOWELL
VALDESE GENERAL HOSPITAL, INC. BURKE
REGION 2
ALAMANCE REGIONAL MEDICAL CENTER ALAMANCE
ANNIE PENN HOSPITAL ROCKINGHAM
CONE HEALTH GUILFORD
FORSYTH MEMORIAL HOSPITAL FORSYTH
HIGH POINT REGIONAL HEALTH SYSTEM GUILFORD
HUGH CHATHAM MEMORIAL HOSPITAL, INC. SURRY
LEXINGTON MEDICAL CENTER DAVIDSON
MEDICAL PARK HOSPITAL, INC. FORSYTH
MOREHEAD MEMORIAL HOSPITAL ROCKINGHAM
NORTH CAROLINA BAPTIST HOSPITAL FORSYTH
NORTHERN HOSPITAL OF SURRY COUNTY SURRY
RANDOLPH HOSPITAL, INC. RANDOLPH
THOMASVILLE MEDICAL CENTER DAVIDSON
WATAUGA MEDICAL CENTER, INC. WATAUGA
WILKES REGIONAL MEDICAL CENTER WILKES
REGION 3
DUKE RALEIGH HOSPITAL WAKE
DUKE UNIVERSITY HOSPITAL DURHAM
DURHAM REGIONAL HOSPITAL DURHAM
FRANKLIN REGIONAL MEDICAL CENTER FRANKLIN
GRANVILLE HEALTH SYSTEM GRANVILLE
JOHNSTON MEMORIAL HOSPITAL JOHNSTON
MARIA PARHAM MEDICAL CENTER VANCE
PERSON MEMORIAL HOSPITAL PERSON
REX HOSPITAL WAKE
UNIVERSITY OF NORTH CAROLINA HOSPITALS ORANGE
WAKEMED WAKE
WAKEMED CARY HOSPITAL WAKE
REGION 4
ALBEMARLE HOSPITAL PASQUOTANK
CAROLINAEAST MEDICAL CENTER CRAVEN
CARTERET GENERAL HOSPITAL CARTERET
FACILITY COUNTY
HALIFAX REGIONAL MEDICAL CENTER, INC. HALIFAX
LENOIR MEMORIAL HOSPITAL, INC. LENOIR
MARTIN GENERAL HOSPITAL MARTIN
NASH GENERAL HOSPITAL NASH
ONSLOW MEMORIAL HOSPITAL, INC. ONSLOW
VIDANT EDGECOMBE HOSPITAL EDGECOMBE
VIDANT BEAUFORT HOSPITAL BEAUFORT
VIDANT DUPLIN HOSPITAL DUPLIN
VIDANT MEDICAL CENTER PITT
VIDANT ROANOKE-CHOWAN HOSPITAL HERTFORD
WAYNE MEMORIAL HOSPITAL, INC. WAYNE
WILSON MEDICAL CENTER WILSON
REGION 5
ANSON COMMUNITY HOSPITAL ANSON
BETSY JOHNSON HOSPITAL HARNETT
BRUNSWICK NOVANT MEDICAL CENTER BRUNSWICK
CAPE FEAR VALLEY MEDICAL CENTER CUMBERLAND
CENTRAL CAROLINA HOSPITAL LEE
COLUMBUS REGIONAL HEALTHCARE SYSTEM COLUMBUS
FIRSTHEALTH MOORE REG. HOSPITAL MOORE
FIRSTHEALTH RICHMOND MEMORIAL HOSPITAL RICHMOND
NEW HANOVER REGIONAL MEDICAL CENTER NEW HANOVER
SAMPSON REGIONAL MEDICAL CENTER SAMPSON
SANDHILLS REGIONAL MEDICAL CENTER RICHMOND
SCOTLAND MEMORIAL HOSPITAL AND EDWIN MORGAN CENTER
SCOTLAND
SOUTHEASTERN REGIONAL MEDICAL CENTER ROBESON
REGION 6
CAROLINAS MEDICAL CENTER- LINCOLN LINCOLN
CAROLINAS MEDICAL CENTER MERCY MECKLENBURG
CAROLINAS MEDICAL CENTER PINEVILLE MECKLENBURG
CAROLINAS MEDICAL CENTER MECKLENBURG
CAROLINAS MEDICAL CENTER-NORTHEAST CABARRUS
CAROLINAS MEDICAL CENTER-UNION UNION
CAROLINAS MEDICAL CENTER-UNIVERSITY MECKLENBURG
CLEVELAND REGIONAL MEDICAL CENTER CLEVELAND
DAVIS REGIONAL MEDICAL CENTER IREDELL
GASTON MEMORIAL HOSPITAL GASTON
IREDELL MEMORIAL HOSPITAL, INC. IREDELL
KINGS MOUNTAIN HOSPITAL CLEVELAND
LAKE NORMAN REGIONAL MEDICAL CENTER IREDELL
PRESBYTERIAN HOSPITAL MECKLENBURG
PRESBYTERIAN HOSPITAL HUNTERSVILLE MECKLENBURG
PRESBYTERIAN HOSPITAL MATTHEWS MECKLENBURG
ROWAN REGIONAL MEDICAL CENTER ROWAN
STANLY REGIONAL MEDICAL CENTER STANLY
21
Appendix B. Eligible Licensed Nursing Homes by NCHA Region
FACILITY COUNTY
REGION 1
ABERNETHY LAURELS CATAWBA
ASHEVILLE HEALTH CARE CENTER BUNCOMBE
ASHEVILLE NURSING & REHABILITATION CENTER BUNCOMBE
ASTON PARK HEALTH CARE CENTER INC BUNCOMBE
AUTUMN CARE OF DREXEL BURKE
AUTUMN CARE OF FOREST CITY RUTHERFORD
AUTUMN CARE OF MARION MCDOWELL
AUTUMN CARE OF SALUDA POLK
AUTUMN CARE OF WAYNESVILLE HAYWOOD
BEYSTONE HEALTH & REHABILITATION HENDERSON
BRIAN CENTER HEALTH &
REHABILITATION/HENDERSONVILLE
HENDERSON
BRIAN CENTER HEALTH & REHABILITATION/HICKORY EAST CATAWBA
BRIAN CENTER HEALTH & REHABILITATION/SPRUCE PINE MITCHELL
BRIAN CENTER HEALTH & REHABILITATION/WEAVERVILLE BUNCOMBE
BRIAN CENTER HEALTH AND REHABILITATION
HICKORY/VIEWMONT
CATAWBA
BRIAN CENTER HEALTH AND REHABILITATION/BREVARD TRANSYLVANIA
BRIAN CENTER HEALTH AND REHABILITATION/WAYNESVILLE HAYWOOD
BROOKS-HOWELL HOME BUNCOMBE
BROOKSIDE REHABILITATION AND CARE YANCEY
CAMELOT MANOR NURSING CARE FACILITY INC CALDWELL
CAROLINA REHAB CENTER OF BURKE BURKE
CAROLINA VILLAGE INC HENDERSON
CLAY COUNTY CARE CENTER CLAY
COLLEGE PINES HEALTH AND REHAB CENTER BURKE
CONOVER NURSING AND REHABILITATION CENTER CATAWBA
DEERFIELD EPISCOPAL RETIREMENT COMMUNITY INC BUNCOMBE
ELDERBERRY HEALTH CARE MADISON
EMERALD RIDGE REHABILITATION AND CARE CENTER BUNCOMBE
FAIR HAVEN HOME RUTHERFORD
FLESHER'S FAIRVIEW HEALTH CARE CENTER INC BUNCOMBE
GATEWAY REHABILITATION AND HEALTHCARE CALDWELL
GIVENS HEALTH CENTER BUNCOMBE
GOLDEN LIVINGCENTER-ASHEVILLE BUNCOMBE
GOLDEN LIVINGCENTER-HENDERSONVILLE HENDERSON
FACILITY COUNTY
GRACE HEIGHTS HEALTH AND REHABILITATION CENTER BURKE
GRACE RIDGE BURKE
GRAHAM HEALTHCARE AND REHABILITATION CENTER GRAHAM
HENDERSONVILLE HEALTH AND REHABILITATION HENDERSON
HIGHLAND FARMS BUNCOMBE
LENOIR HEALTHCARE CENTER CALDWELL
LIFE CARE CENTER OF BANNER ELK AVERY
LIFE CARE CENTER OF HENDERSONVILLE HENDERSON
MACON VALLEY NURSING AND REHABILITATION CENTER MACON
MADISON HEALTH AND REHABILITATION MADISON
MAGGIE VALLEY NURSING AND REHABILITATION HAYWOOD
MAGNOLIA LANE NURSING AND REHABILITATION CENTER BURKE
MOUNTAIN HOME HEALTH AND REHAB HENDERSON
MOUNTAIN RIDGE HEALTH AND REHAB BUNCOMBE
MOUNTAIN TRACE REHABILITATION & NURSING CENTER JACKSON
MOUNTAIN VIEW MANOR NURSING CENTER SWAIN
NC STATE VETERANS HOME-BLACK MOUNTAIN BUNCOMBE
OAK GROVE HEALTHCARE CENTER RUTHERFORD
PISGAH MANOR HEALTH CARE CENTER BUNCOMBE
SHAIRE NURSING CENTER CALDWELL
SILVER BLUFF LLC HAYWOOD
SKYLAND CARE CENTER JACKSON
SMOKY MOUNTAIN HEALTH AND REHABILITATION CENTER HAYWOOD
STONECREEK HEALTH AND REHABILITATION BUNCOMBE
SUNRISE REHABILIATION & CARE MCDOWELL
THE LAURELS OF GREENTREE RIDGE BUNCOMBE
THE LAURELS OF HENDERSONVILLE HENDERSON
THE LAURELS OF SUMMIT RIDGE BUNCOMBE
THE OAKS AT SWEETEN CREEK BUNCOMBE
THE OAKS OF BREVARD TRANSYLVANIA
TRINITY RIDGE CATAWBA
TRINITY VILLAGE CATAWBA
UNIVERSAL HEALTH CARE/FLETCHER HENDERSON
VALLEY NURSING CENTER ALEXANDER
VALLEY VIEW CARE AND REHABILITATION CENTER CHEROKEE
WESTERN NORTH CAROLINA BAPTIST HOME BUNCOMBE
22
FACILITY COUNTY
WHITE OAK MANOR-RUTHERFORDTON RUTHERFORD
WHITE OAK MANOR-TRYON POLK
WILLOW RIDGE OF NC LLC RUTHERFORD
WILLOWBROOKE COURT SC CENTER AT TRYON ESTATES POLK
REGION 2
ABBOTTS CREEK CENTER DAVIDSON
ADAMS FARM LIVING & REHABILITATION GUILFORD
ALAMANCE HEALTH CARE CENTER ALAMANCE
ALLEGHANY CENTER ALLEGHANY
ALSTON BROOK DAVIDSON
ARBOR ACRES UNITED METHODIST RETIREMENT
COMMUNITY INC
FORSYTH
ASHTON PLACE HEALTH & REHAB GUILFORD
AUTUMN CARE OF MOCKSVILLE DAVIE
AVANTE AT REIDSVILLE ROCKINGHAM
AVANTE AT WILKESBORO WILKES
BERMUDA COMMONS NURSING AND REHABILITATION
CENTER
DAVIE
BERMUDA VILLAGE RETIREMENT CENTER DAVIE
BLOWING ROCK REHAB DAVANT EXTENDED CARE CTR WATAUGA
BLUMENTHAL JEWISH NURSING & REHAB CENTER GUILFORD
BRIAN CENTER HEALTH & REHABILITATION/YANCEYVILLE CASWELL
BRIAN CENTER HEALTH & RETIREMENT/WINSTON SALEM FORSYTH
BRIAN CENTER HEALTH AND REHABILITATION/EDEN ROCKINGHAM
BRIAN CENTER NURSING CARE/LEXINGTON DAVIDSON
BROOKRIDGE RETIREMENT COMMUNITY FORSYTH
CAMDEN PLACE HEALTH & REHAB LLC GUILFORD
CENTRAL CONTINUING CARE SURRY
CLAPP'S CONVALESCENT NURSING HOME INC RANDOLPH
CLAPPS NURSING CENTER INC GUILFORD
CLEMMONS NURSING & REHAB CENTER FORSYTH
COUNTRYSIDE MANOR INC GUILFORD
EDGEWOOD PLACE AT THE VILLAGE AT BROOKWOOD ALAMANCE
FRIENDS HOMES AT GUILFORD GUILFORD
FRIENDS HOMES WEST GUILFORD
GLENBRIDGE HEALTH AND REHABILITATION WATAUGA
GOLDEN LIVINGCENTER-GREENSBORO GUILFORD
GOLDEN LIVINGCENTER-STARMOUNT GUILFORD
FACILITY COUNTY
GOLDEN LIVINGCENTER-SURRY COMMUNITY SURRY
GREENHAVEN HEALTH AND REHABILITATION CENTER GUILFORD
GUILFORD HEALTH CARE CENTER GUILFORD
HEARTLAND LIVING & REHAB @ THE MOSES H CONE MEM
HOSP
GUILFORD
HOMESTEAD HILLS FORSYTH
JACOB'S CREEK NURSING AND REHABILITATION CENTER ROCKINGHAM
KINDRED TRANSITIONAL CARE AND REHAB-SILAS CREEK FORSYTH
LEXINGTON HEALTH CARE CENTER DAVIDSON
LIBERTY COMMONS NSG & REHAB CTR OF SPRINGWOOD FORSYTH
LIBERTY COMMONS NURSING & REHAB CTR OF ALAMANCE
CTY
ALAMANCE
LIBERTYWOOD NURSING CENTER DAVIDSON
MAPLE GROVE HEALTH AND REHABILITATION CENTER GUILFORD
MARGATE HEALTH AND REHAB CENTER ASHE
MARYFIELD NURSING HOME GUILFORD
MOUNTAIN VISTA HEALTH PARK DAVIDSON
OAK FOREST HEALTH AND REHABILITATION FORSYTH
PEAK RESOURCES-ALAMANCE INC ALAMANCE
PENN NURSING CENTER ROCKINGHAM
PIEDMONT CROSSING DAVIDSON
PINE RIDGE HEALTH AND REHABILITATION CENTER DAVIDSON
PINEY GROVE NURSING AND REHABILITATION CENTER FORSYTH
RANDOLPH HEALTH AND REHABILITATION CENTER RANDOLPH
RIVER LANDING AT SANDY RIDGE GUILFORD
SALEMTOWNE FORSYTH
THE GRAYBRIER NURSING AND RETIREMENT CENTER RANDOLPH
THE OAKS FORSYTH
THE PRESBYTERIAN HOME OF HAWFIELDS INC ALAMANCE
THE SHANNON GRAY REHABILITATION & RECOVERY CENTER GUILFORD
TRIAD CENTER GUILFORD
TRINITY GLEN FORSYTH
TWIN LAKES COMMUNITY ALAMANCE
TWIN LAKES COMMUNITY MEMORY CARE ALAMANCE
UNIHEALTH POST-ACUTE CARE-ELKIN SURRY
UNIHEALTH POST-ACUTE CARE-HIGH POINT FORSYTH
UNIVERSAL HEALTH CARE/KING STOKES
UNIVERSAL HEALTH CARE/RAMSEUR RANDOLPH
23
FACILITY COUNTY
VILLAGE CARE OF KING STOKES
WALNUT COVE HEALTH AND REHABILITATION CENTER STOKES
WELL-SPRING GUILFORD
WESTCHESTER MANOR AT PROVIDENCE PLACE GUILFORD
WESTWOOD HEALTH AND REHABILITATION CENTER RANDOLPH
WESTWOOD HILLS NURSING AND REHABILITATION CENTER WILKES
WHITE OAK MANOR-BURLINGTON ALAMANCE
WHITESTONE: A MASONIC AND EASTERN STAR
COMMUNITY
GUILFORD
WILKES SENIOR VILLAGE WILKES
WILLOWBROOK REHABILITATION AND CARE CENTER YADKIN
WINSTON SALEM NURSING & REHABILITATION CENTER FORSYTH
WOODLAND HILL CENTER RANDOLPH
YADKIN NURSING CARE CENTER YADKIN
REGION 3
BARBOUR COURT NURSING AND REHABILITATION CENTER JOHNSTON
BRIAN CENTER HEALTH & RETIREMENT/CLAYTON JOHNSTON
BRIAN CENTER HEALTH AND REHABILITATION/DURHAM DURHAM
BRITTANY PLACE WAKE
BRITTHAVEN OF CHAPEL HILL ORANGE
BROOKSHIRE NURSING CENTER ORANGE
CAPITAL NURSING AND REHABILITATION CENTER WAKE
CAROL WOODS ORANGE
CAROLINA MEADOWS HEALTH CENTER CHATHAM
CARVER LIVING CENTER DURHAM
CARY HEALTH AND REHABILITATION CENTER WAKE
CHAPEL HILL HEALTHCARE AND REHABILITATION CENTER ORANGE
CRABTREE VALLEY REHAB CENTER WAKE
CROASDAILE VILLAGE DURHAM
DAN E & MARY LOUISE STEWART HEALTH CENTER OF WAKE
DURHAM NURSING & REHABILITATION CENTER DURHAM
FRANKLIN OAKS NURSING AND REHABILITATION CENTER FRANKLIN
GLENAIRE WAKE
HILLCREST CONVALESCENT CENTER INC DURHAM
HILLSIDE NURSING CENTER OF WAKE FOREST WAKE
KERR LAKE NURSING AND REHABILITATION CENTER VANCE
KINDRED NURSING AND REHABILITATION-HENDERSON VANCE
KINDRED NURSING AND REHABILITATION-ZEBULON WAKE
FACILITY COUNTY
KINDRED TRANSITIONAL CARE AND REHAB-PETTIGREW DURHAM
KINDRED TRANSITIONAL CARE AND REHAB-RALEIGH WAKE
KINDRED TRANSITIONAL CARE AND REHAB-ROSE MANOR DURHAM
KINDRED TRANSITIONAL CARE AND REHAB-SUNNYBROOK WAKE
LIBERTY COMMONS NSG AND REHAB CTR OF JOHNSTON CTY JOHNSTON
LITCHFORD FALLS HEALTHCARE AND REHABILITATION
CENTER
WAKE
LOUISBURG NURSING CENTER FRANKLIN
PEAK RESOURCES-TREYBURN DURHAM
REX REHABILITATION AND NURSING CARE CENTER OF APEX WAKE
ROXBORO HEALTHCARE & REHABILITATION CENTER PERSON
SENIOR CITIZEN'S HOME INC VANCE
SILER CITY CENTER CHATHAM
SMITHFIELD MANOR INC JOHNSTON
THE ARBOR CHATHAM
THE CEDARS OF CHAPEL HILL DURHAM
THE FOREST AT DUKE DURHAM
THE LAURELS OF CHATHAM CHATHAM
THE LAURELS OF FOREST GLENN WAKE
THE OAKS AT MAYVIEW WAKE
THE ROSEWOOD HEALTH CENTER WAKE
TOWER NURSING AND REHABILITATION CENTER WAKE
UNIHEALTH POST-ACUTE CARE OF DURHAM DURHAM
UNIHEALTH POST-ACUTE CARE-CAROLINA POINT ORANGE
UNIHEALTH POST-ACUTE CARE-RALEIGH WAKE
UNIVERSAL HEALTH CARE / NORTH RALEIGH WAKE
UNIVERSAL HEALTH CARE/FUQUAY-VARINA WAKE
UNIVERSAL HEALTH CARE/OXFORD GRANVILLE
WARREN HILLS, A PERSONAL CARE & NURSING FACILITY WARREN
WELLINGTON REHABILITATION AND HEALTHCARE WAKE
WINDSOR POINT CONTINUING CARE RETIREMENT
COMMUNITY
WAKE
REGION 4
AUTUMN CARE OF NASH NASH
AVANTE AT WILSON WILSON
AYDEN COURT NURSING AND REHABILITATION CENTER PITT
BAYVIEW NURSING & REHABILITATION CENTER CRAVEN
BRIAN CENTER HEALTH & REHABILITATION/WALLACE DUPLIN
24
FACILITY COUNTY
BRIAN CENTER HEALTH & REHABILITATION/WILSON WILSON
BRIAN CENTER HEALTH & REHABILITATION/WINDSOR BERTIE
BRIAN CENTER HEALTH AND REHABILITATION/GOLDSBORO WAYNE
BRIAN CENTER HEALTH AND REHABILITATION/HERTFORD PERQUIMANS
BROOK STONE LIVING CENTER JONES
CAROLINA RIVERS NURSING AND REHABILITATION CENTER ONSLOW
CHERRY POINT BAY NURSING AND REHABILITATION CENTER CRAVEN
CHOWAN RIVER NURSING AND REHABILITATION CENTER CHOWAN
COLONY RIDGE NURSING AND REHABILITATION CENTER DARE
CREEKSIDE CARE & REHABILITATION CENTER HERTFORD
CROATAN RIDGE NURSING AND REHABILITATION CENTER CARTERET
CROSS CREEK HEALTH CARE HYDE
CRYSTAL BLUFFS REHABILITATION AND HEALTH CARE
CENTER
CARTERET
CYPRESS GLEN RETIREMENT COMMUNITY PITT
DOWN EAST HEALTH AND REHABILITATION CENTER GATES
ENFIELD OAKS NURSING AND REHABILITATION CENTER HALIFAX
GOLDEN LIVINGCENTER-GREENVILLE PITT
GOLDEN LIVINGCENTER-TARBORO EDGECOMBE
GRANTSBROOK NURSING AND REHABILITATION CENTER PAMLICO
GREENDALE FOREST NURSING AND REHABILITATION CENTER GREENE
GREENFIELD PLACE LLC PITT
HARBORVIEW HEALTH CARE CENTER CARTERET
HARMONY HALL NURSING AND REHABILITATION CENTER LENOIR
HERITAGE HEALTHCARE AT TAYLOR PLACE CARTERET
HERITAGE HEALTHCARE OF FARMVILLE PITT
HUNTER HILLS NURSING AND REHABILITATION CENTER NASH
KENANSVILLE HEALTH & REHABIILTATION CENTER DUPLIN
KINDRED TRANSITIONAL CARE AND REHAB-ELIZABETH CITY PASQUOTANK
KINDRED TRANSITIONAL CARE AND REHAB-ROCKY MOUNT NASH
KINSTON HEALTHCARE AND REHABILITATION CENTER LENOIR
LIBERTY COMMONS NSG AND REHAB CTR OF HALIFAX
COUNTY
HALIFAX
MOUNT OLIVE CENTER WAYNE
NC STATE VETERANS NURSING HOME-KINSTON LENOIR
NORTHAMPTON NURSING AND REHABILITATION CENTER NORTHAMPTON
PREMIER NURSING AND REHABILITATION CENTER ONSLOW
RICH SQUARE HEALTH CARE CENTER NORTHAMPTON
FACILITY COUNTY
RIDGEWOOD MANOR INC BEAUFORT
RIVER TRACE NURSING AND REHABILITATION CENTER BEAUFORT
RIVERPOINT CREST NURSING AND REHABILITATION CENTER CRAVEN
ROANOKE LANDING NURSING AND REHABILITATION CENTER WASHINGTON
ROANOKE RAPIDS HEALTHCARE AND REHABILITATION
CENTER
HALIFAX
ROANOKE RIVER NURSING AND REHABILITATION CENTER MARTIN
SCOTLAND MANOR HEALTH CARE CENTER HALIFAX
SENTARA NURSING CENTER-CURRITUCK CURRITUCK
SNUG HARBOR ON NELSON BAY CARTERET
SOUTH VILLAGE NASH
TARBORO NURSING CENTER EDGECOMBE
THE FOUNTAINS AT THE ALBEMARLE EDGECOMBE
THREE RIVERS HEALTH AND REHAB BERTIE
UNIHEALTH POST-ACUTE CARE-NEUSE CRAVEN
UNIHEALTH POST-ACUTE CARE-TRENT CRAVEN
UNIVERSAL HEALTH CARE/GREENVILLE PITT
UNIVERSAL HEALTH CARE/NASHVILLE NASH
W. R. WINSLOW MEMORIAL HOME PASQUOTANK
WARSAW HEALTH & REHABILITATION CENTER DUPLIN
WILLOW CREEK NURSING AND REHABILITATION CENTER WAYNE
WILMED NURSING CARE CENTER WILSON
WILSON PINES NURSING AND REHABILITATION CENTER WILSON
REGION 5
AMBASSADOR HEALTH & REHAB OF WADESBORO LLC ANSON
AUTUMN CARE OF BISCOE MONTGOMERY
AUTUMN CARE OF FAYETTEVILLE CUMBERLAND
AUTUMN CARE OF MYRTLE GROVE NEW HANOVER
AUTUMN CARE OF RAEFORD HOKE
AUTUMN CARE OF SHALLOTTE BRUNSWICK
AZALEA HEALTH & REHAB CENTER NEW HANOVER
BETHESDA HEALTH CARE FACILITY CUMBERLAND
BRUNSWICK COVE NURSING CENTER BRUNSWICK
CAROLINA REHAB CENTER OF CUMBERLAND CUMBERLAND
CORNERSTONE NURSING AND REHABILITATION CENTER HARNETT
CUMBERLAND NURSING AND REHABILITATION CENTER CUMBERLAND
DAVIS HEALTH CARE CENTER NEW HANOVER
ELIZABETHTOWN HEALTHCARE & REHABILITATION CENTER BLADEN
25
FACILITY COUNTY
EMERALD HEALTH & REHAB HARNETT
GLENFLORA ROBESON
GOLDEN LIVINGCENTER-LUMBERTON ROBESON
GOLDEN YEARS NURSING HOME CUMBERLAND
HARNETT WOODS NURSING AND REHABILITATION CENTER HARNETT
HAYMOUNT REHABILITATION & NURSING CENTER INC CUMBERLAND
HIGHLAND ACRES NURSING AND REHABILITATION CENTER ROBESON
HIGHLAND HOUSE REHABILITATION AND HEALTHCARE CUMBERLAND
HUNTINGTON HEALTH CARE PENDER
INN AT QUAIL HAVEN VILLAGE MOORE
KINDRED TRANSITIONAL CARE AND REHAB-CYPRESS POINTE NEW HANOVER
KINGSWOOD NURSING CENTER MOORE
LIBERTY COMMONS NSG AND REHAB CTR OF LEE COUNTY
LLC
LEE
LIBERTY COMMONS NURSING AND REHAB CTR OF
COLUMBUS CTY
COLUMBUS
LIBERTY COMMONS REHABILITATION CENTER NEW HANOVER
MANOR CARE HEALTH SERVICES-PINEHURST MOORE
MARY GRAN NURSING CENTER SAMPSON
NORTH CAROLINA STATE VETERANS NURSING HOME CUMBERLAND
NORTHCHASE NURSING AND REHABILITATION CENTER NEW HANOVER
OCEAN TRAIL HEALTHCARE & REHABILITATION CENTER BRUNSWICK
PEAK RESOURCES-PINELAKE MOORE
PEMBROKE CENTER ROBESON
PENICK VILLAGE MOORE
PINEHURST HEALTHCARE & REHABILITATION CENTER MOORE
POPLAR HEIGHTS CENTER BLADEN
PREMIER LIVING AND REHAB CENTER COLUMBUS
RICHMOND PINES HEALTHCARE AND REHABILITATION
CENTER
RICHMOND
ROCKINGHAM MANOR RICHMOND
SANFORD HEALTH & REHABILITATION CO LEE
SCOTIA VILLAGE SCOTLAND
SCOTTISH PINES REHABILITATION AND NURSING CENTER SCOTLAND
SHORELAND HEALTH CARE AND RETIREMENT CENTER INC COLUMBUS
SILVER STREAM HEALTH AND REHABILITATION CENTER NEW HANOVER
SOUTHWOOD NURSING AND RETIREMENT CENTER SAMPSON
ST JOSEPH OF THE PINES HEALTH CENTER MOORE
FACILITY COUNTY
THE REHABILITATION AND HEALTH CARE CTR AT VILLAGE
GREEN
CUMBERLAND
TRINITY GROVE NEW HANOVER
UNIVERSAL HEALTH CARE LILLINGTON HARNETT
UNIVERSAL HEALTH CARE/BRUNSWICK BRUNSWICK
WESLEY PINES RETIREMENT COMMUNITY ROBESON
WESTFIELD REHABILITATION AND HEALTH CENTER LEE
WHISPERING PINES NURSING & REHABILITATION CENTER CUMBERLAND
WILMINGTON HEALTH AND REHABILITATION CENTER NEW HANOVER
WOODBURY WELLNESS CENTER INC PENDER
WOODLANDS NURSING & REHABILITATION CENTER CUMBERLAND
REGION 6
ALEXANDRIA PLACE GASTON
ASBURY CARE CENTER MECKLENBURG
AUTUMN CARE OF MARSHVILLE UNION
AUTUMN CARE OF SALISBURY ROWAN
AUTUMN CARE OF STATESVILLE IREDELL
AVANTE AT CHARLOTTE MECKLENBURG
AVANTE AT CONCORD CABARRUS
BELAIRE HEALTH CARE CENTER GASTON
BETHANY WOODS NURSING AND REHABILITATION CENTER STANLY
BIG ELM RETIREMENT AND NURSING CENTERS ROWAN
BRIAN CENTER HEALTH & REHABILITATION/SALISBURY ROWAN
BRIAN CENTER HEALTH & REHABILITATION/STATESVILLE IREDELL
BRIAN CENTER HEALTH & RETIREMENT/CABARRUS CABARRUS
BRIAN CENTER HEALTH & RETIREMENT/LINCOLNTON LINCOLN
BRIAN CENTER HEALTH & RETIREMENT/MONROE UNION
BRIAN CENTER HEALTH & RETIREMENT/MOORESVILLE IREDELL
BRIAN CENTER HEALTH AND REHABILITATION/CHARLOTTE MECKLENBURG
BRIAN CENTER HEALTH AND REHABILITATION/GASTONIA GASTON
BRIAN CENTER NURSING CARE/SHAMROCK MECKLENBURG
BRIGHTMOOR NURSING CENTER ROWAN
CARDINAL HEALTHCARE AND REHABILITATION CENTER LINCOLN
CAROLINA CARE CENTER GASTON
CARRINGTON PLACE MECKLENBURG
CHARLOTTE HEALTH CARE CENTER MECKLENBURG
CLEAR CREEK NURSING & REHABILITATION CENTER MECKLENBURG
CLEVELAND PINES NURSING CENTER CLEVELAND
26
FACILITY COUNTY
COURTLAND TERRACE GASTON
COVENANT VILLAGE INC GASTON
FIVE OAKS MANOR CABARRUS
FORREST OAKES HEALTHCARE CENTER STANLY
GASTONIA HEALTHCARE AND REHABILITATION CENTER GASTON
GOLDEN LIVINGCENTER-CHARLOTTE MECKLENBURG
GOLDEN LIVINGCENTER-DARTMOUTH MECKLENBURG
HUNTER WOODS NURSING AND REHABILITATION CENTER MECKLENBURG
HUNTERSVILLE OAKS MECKLENBURG
KINDRED NURSING AND REHABILITATION-LINCOLN LINCOLN
KINDRED TRANSITIONAL CARE AND REHAB-MONROE UNION
LAKE PARK NURSING AND REHABILITATION CENTER UNION
LIBERTY COMMONS NSG AND REHAB CTR OF ROWAN CTY ROWAN
MAGNOLIA ESTATES SKILLED CARE FACILITY ROWAN
MAPLE LEAF HEALTH CARE IREDELL
MEADOWWOOD NURSING CENTER GASTON
MECKLENBURG HEALTH & REHABILITATION CENTER MECKLENBURG
MOORESVILLE CENTER IREDELL
NORTH CAROLINA STATE VETERANS NURSING HOME
SALISBURY
ROWAN
OLDE KNOX COMMONS AT THE VILLAGES OF MECKLENBURG MECKLENBURG
PAVILION HEALTH CENTER AT BRIGHTMORE MECKLENBURG
PEAK RESOURCES-CHARLOTTE MECKLENBURG
PEAK RESOURCES-CHERRYVILLE GASTON
PEAK RESOURCES-GASTONIA GASTON
PEAK RESOURCES-SHELBY CLEVELAND
PINEVILLE REHABILITATION AND LIVING CENTER MECKLENBURG
ROYAL PARK REHABILITATION & HEALTH CENTER MECKLENBURG
SALISBURY CENTER ROWAN
SARDIS OAKS MECKLENBURG
SATURN NURSING AND REHABILITATION CENTER MECKLENBURG
SHARON TOWERS MECKLENBURG
SOUTHMINSTER MECKLENBURG
STANLEY TOTAL LIVING CENTER INC GASTON
STANLY MANOR STANLY
THE CARRIAGE CLUB OF CHARLOTTE MECKLENBURG
THE GARDENS OF TAYLOR GLEN RETIREMENT COMMUNITY CABARRUS
THE LAURELS OF SALISBURY ROWAN
FACILITY COUNTY
THE OAKS AT TOWN CENTER CABARRUS
THE PINES AT DAVIDSON MECKLENBURG
THE STEWART HEALTH CENTER MECKLENBURG
TRANSITIONAL HEALTH SERVICES OF KANNAPOLIS CABARRUS
TRINITY OAKS ROWAN
TRINITY PLACE STANLY
UNIVERSAL HEALTH CARE AND REHABILITATION CENTER CABARRUS
UNIVERSITY PLACE NURSING AND REHABILITATION CENTER MECKLENBURG
WHITE OAK MANOR-CHARLOTTE MECKLENBURG
WHITE OAK MANOR-KINGS MOUNTAIN CLEVELAND
WHITE OAK MANOR-SHELBY CLEVELAND
WHITE OAK OF WAXHAW UNION
WILLOWBROOKE COURT SC CTR AT PLANTATION ESTATES MECKLENBURG
WILORA LAKE HEALTHCARE CENTER MECKLENBURG